It’s as predictable as the Republican call for “thoughts and prayers”: After a mass shooting involving an assault weapon comes a chorus of voices wanting to make it easier to lock up the “crazy” people. After the Parkland shootings, our fearless leader Donald Trump opined, “Part of the problem is we used to have mental institutions . . . where you take a sicko like this guy,” referring to Nikolas Cruz, the shooter in the Marjory Stoneman Douglas High School tragedy in Florida on Valentine’s Day 2018. “We’re going to be talking seriously about opening mental health institutions again.”

Alisa Roth’s powerful new book, Insane: America’s Criminal Treatment of Mental Illness, calls into question such simplistic solutions to the current crisis in our mental health-care system. As she shows in this engaging work of narrative journalism, we already treat mental illness like a crime in this country. Roth, a journalist whose work appears regularly on NPR and in other media outlets, combines searing anecdotes with compelling statistics to expose a reality well known among mental-health experts but largely hidden from the public: that the largest mental health-care providers in the United States today are jails and prisons, where people with mental illness are treated as badly—and often worse—than inmates in the custodial mental hospitals of the past. For many Americans, especially those at higher risk of incarceration because of the color of their skin, the correctional system has become the new asylum. Insane delivers a heart-wrenching account of the tragedies unfolding in these correctional facilities turned into makeshift mental hospitals.

How did jails and prisons end up being the front line of mental-health care provision? Roth rightly critiques the knee-jerk reaction that blames this development solely on the closure of failing mental hospitals in the 1970s and ‘80s. The people moldering in the “snake pits” of old were predominantly elderly, white, female, and suffered from serious, chronic mental illnesses; after the passage of Medicare in 1965, their care was shifted to nursing homes. Meanwhile, overall funding to provide inpatient psychiatric care steadily declined in the late twentieth century, leaving patients and families with fewer and fewer resources to call upon. For the sickest and poorest Americans, jails and prisons became the default option for care. “People with mental illness have simply been caught up—albeit sometimes in disproportionately higher numbers than the rest of the population—by the same forces that have driven the rise of mass incarceration, among them the War on Drugs, broken windows policing, and mandatory minimum sentencing,” Roth writes. Once in the correctional system, they are treated not as sick people but as criminals, often with disastrous results.

Roth uses her considerable skills as an investigative reporter to survey this new landscape of confinement. Based on in-depth interviews and observations, the book provides revealing snapshots of conditions at New York City’s Rikers Island, the Los Angeles County jail, and Chicago’s Cook County jail, the nation’s de facto three largest mental health-care providers. She also reports on states such as Oklahoma and Alabama that combine high rates of mental illness with low expenditures on its treatment, both inside and outside prisons. We meet many memorable characters: the white ex-firefighter who ended up blinding himself in solitary confinement; the black man living on the University of Minnesota campus who was arrested 200 times between 1996 and 2012; the white teenager convicted as an accessory to murder who spent 23 years in solitary; the young black man found sleeping on a park bench who was fatally shot by the police. Most of Roth’s stories are about men; although women in the correctional system suffer from higher rates of mental illness, there are far fewer of them.

Like a journalist Virgil, Roth is our guide to the seven circles of prison hell and their unique horrors: the exercise spaces constructed like dog runs at the kennel; the special knife that correction officers carry so they can cut down people trying to hang themselves; the cell phone bar code system used to verify that prisoners in solitary confinement are still alive; the “therapy” offered in conversations conducted through the tray slot in the cell door. She is remarkably evenhanded to guards in attributing these hellish conditions not just to the failings of human nature (although they are certainly on display), but also to the overcrowding, understaffing, and lack of training that exist in many correctional facilities.

Medical facilities are designed to treat illnesses, and correctional facilities to punish crime. Thus, their cultures are in perpetual conflict.

At the heart of the matter is a clash of values that recurs throughout the book. Medical facilities are designed to treat illnesses, correctional facilities to punish crime. Thus, their cultures are in perpetual conflict. As Roth observes, the criminal justice system is “built around a punitive, authority-based approach.” In the name of preserving order and safety, it emphasizes control for control’s sake and rules for rules’ sake. This is obviously problematic because, as Roth puts it, “For a person with symptoms of mental illness, it can be nearly impossible to obey the rules.” In this climate, misunderstanding occurs on both sides, often with violent results. The person with mental illness reacts badly to the assertion of control and acts out, the officer interprets the acting out as a symptom of insubordination and potential dangerousness, and the cycle continues.

The fear of violence dominates this interaction. As a group, people with mental illness are more likely to be victims than perpetrators of violent crime, and are more likely to be victims than the population at large. Many people with mental illness who end up in jail have committed only minor infractions such as shoplifting, vagrancy, and turnstile jumping. But the tiny minority of people with psychiatric diagnoses who do act out violently creates a presumption that all people with mental problems should be treated as potentially dangerous. That assumption creates a self-fulfilling prophecy: Officers come on strong and frighten the disturbed person into lashing out. In this atmosphere, it is no easy matter to decide whose right to be protected comes first—the health-care worker socked in the jaw by a frightened inmate, the corrections officers trying to wrestle a delusional man into a cell, or the inmate in solitary confinement who is determined to hang himself.

This same clash of values colors the tense relationships between mental-health professionals and correctional officers. Ironically, thanks to a landmark 1976 Supreme Court decision, Estelle v. Gamble, prisoners are the only Americans who have a constitutional right to medical care, including for psychiatric disorders. Today psychiatrists, physicians, psychologists, art therapists, and social workers are employed in jails and prisons to deliver that care, but always in deference to the correctional officers’ authority. As medical staff put it to Roth, “We are guests in their house.” Roth notes, “This dual loyalty—the tension between medical staff and the correctional work environment—affects all aspects of the job but is little discussed.”

Despite many studies that document the practice’s
toxic psychologic impact, an estimated 80,000 inmates are in solitary confinement.

Practicing mental health care in a correctional facility is an exercise in frustration for all concerned. The imperative to abide by HIPAA rules designed to protect patients’ privacy is a case in point. Overcrowding and safety concerns require that inmates receive what little therapy they get in open spaces where everyone can listen; yet in the name of privacy, corrections officers are often denied vital information about a person’s medical history that could make dealing with them much easier. “It’s the worst of all possible scenarios,” Roth writes. “Medical information that could help deputies understand a person’s behavior is kept secret, but the actual medical care—meetings with a psychiatrist or therapist, for example, is conducted in the open, which, among other things, could make the patient less likely to be honest and forthcoming.”

Even more tragic is the frequent resort to solitary confinement for people with mental illness. Unlike Western European countries, where stringent rules govern its use, there is no agreement in the United States about what constitutes a “reasonable” amount of time to isolate inmates. Despite many studies that document the practice’s toxic psychological impact, an estimated 80,000 American inmates are in solitary, either because they have broken rules or because they are deemed a danger to themselves or others. In solitary, their mental state often deteriorates further, making them even more difficult to manage. “For sick prisoners,” Roth notes, “this means a two-part trap in which they are punished for their ‘abnormal’ behavior with disciplinary measures that, in turn, make their condition worse.” Alone in their cells, inmates show extraordinary ingenuity in harming themselves with mundane objects such as toilet paper and egg shells. Half of all prison suicides occur among inmates in solitary, an astonishing statistic given that the practice is often justified as a way to protect inmates from harm.

The inflexibility of a “one-size-fits-all” model of criminal justice fuels this dysfunction. From courtroom to cell, that system does a poor job of “differentiating between the severity of the different illnesses or the severity of the crimes.” As a result, “the man who was stopped for a traffic violation is essentially treated the same way as the one who tried to kill the tourist.” Both end up in jail being guarded like the “accused criminals they are” by workers who lack specialized training or even information needed “to make informed decisions about their care.” Roth concludes, “It’s a setup that seems destined for failure.”

Breaking this cycle requires early intervention, when the person with mental illness first encounters the sticky web of the criminal justice system. The shift in mindset must start with the police officers and sheriff’s deputies, who often are the first responders called in to deal with individuals having a mental-health meltdown. Crisis Intervention Teams (CIT), first developed in the late 1980s, help officers learn to recognize the symptoms of mental illness and act to de-escalate the situation. CIT programs are now a cornerstone of the effort to return to an older style of community policing. As Mike Woody, an Ohio police officer who does CIT training, puts it, “We are trying to change the warrior mentality back into the guardian mentality.” To encourage this shift, some cities are making it easier for police officers to take people to treatment facilities rather than jail. For example, San Antonio’s Restoration Center offers “a kind of mental health care mall” that includes a crisis center, a sobering center, detox and rehab programs, a methadone clinic, and a homeless shelter, all in close proximity. This combination has proven both therapeutically successful and cost effective. Parallel initiatives to steer troubled people into treatment facilities have also developed in courtrooms across the country. Roth points to the innovative diversion programs being developed in places like Miami-Dade County, where people with mental illness who are arrested for a misdemeanor or nonviolent felony are given the choice between treatment and jail. Eighty percent of them choose treatment, with considerable savings to the city.

Meanwhile, reformers within correctional facilities are attempting to take advantage of their captive audiences to deliver a better quality of psychiatric care, thus increasing the chance that people will recover and avoid a return to jail. Roth highlights the innovative work of Thomas Dart, the sheriff of Cook County, Illinois. He decided that “If they’re going to make it so that I am going to be the largest mental health provider, we’re going to be the best ones.” To that end, in 2015, he hired a clinical psychologist, Nneka Jones Tapia, to run the Cook County jail. Under that leadership, the jail now emphasizes a team-based approach in which corrections officers and mental health-care providers work together. As part of the effort to improve conditions at troubled Rikers Island, a jail that many advocates want to see closed, psychiatrist Elizabeth Ford has implemented a similar strategy—the Program to Accelerate Clinical Effectiveness—in which people with serious mental illnesses are given intensive treatment by medical and corrections staff that train together as a team. The Rikers program suggests that “treating them as patients rather than prisoners brings positive results,” Roth writes.

While emphasizing these reformers’ good intentions, Roth points out the downside of their efforts. Concentrating scarce resources on building better hospital facilities inside jails may just incentivize their use. Long-term change, Roth suggests, requires a different solution: redirecting taxpayer dollars to the prevention and early treatment of mental disorders so that fewer people end up in places like Rikers.

Accentuating the positive when and where she finds it, Roth nonetheless ends the book on a very cautious note. She is not a much of an optimist, hardly surprising given the scale of the problems she documents. Mental illness, she notes, remains a highly stigmatized condition. As she explains, “We know and accept that cancer and other physical disease sometimes recur,” and that quitting an addiction can be hard. “Yet a person with mental illness who ricochets repeatedly between inadequate health care and support in the community and the vortex of the criminal justice systems is seen as a hopeless failure.” Many people simply feel that mental illness is no excuse for bad behavior. Police and corrections officers, for instance, dislike what they regard as the “hug-a-thug” mentality represented in San Antonio’s Restoration Center. The persistent association of mental illness with danger and violence diminishes public sympathy for the plight of those suffering from these ailments and encourages a “lock ‘em up” mentality instead. While we may agree in principle that “It is unfair to convict somebody who didn’t know what he was doing,” Roth writes, we may still “instinctively abhor violent or deviant behavior that is caused by psychosis.” Murderers do not evoke much sympathy, and the impulse to punish them is a strong one.

Then there is also the problem of money. Ever since the 1970s, the U.S. health-care system has become increasingly market-oriented, but the long-term treatment of mental illness and substance abuse is not a big profit maker. Thus, fixing the mental health-care system requires an infusion of taxpayer money unlikely to appear anytime soon. As Roth laments, there remains a “willingness to expend resources in the name of public safety but not public health” that has left us “with an almost single-minded focus on punishment and retribution.”

If the definition of insanity is doing the same thing over and over again and expecting a different outcome, then we are the crazy ones.

The strength of Roth’s book lies in her refusal to oversimplify. That makes for a book that is often difficult to read, but also hard to forget. Her work echoes that of critics who came before her: Dorothea Dix, whose outrage over the mistreatment of the mentally ill in American jails and prisons helped convince state legislatures to open public mental hospitals back in the 1800s, and journalists Albert Deutsch and Albert Maisel, whose exposés of those same hospitals in the 1930s and ’40s helped spark the movement to close them. Like them, Roth writes in hope of provoking change, to get us thinking about how community institutions can be “reenvisioned and reoriented toward prevention and preemption: getting care to the most vulnerable before the criminal justice system takes them.”

But Roth stops short of offering a grand plan to accomplish this goal. “There is no single cause for the crisis of people with mental illness in the criminal justice system,” she argues, and thus “there is also no single fix.” Consistent with that argument, Roth leaves us with no clear-cut, bullet-pointed plan of action. Instead, throughout the book she calls out examples of positive change, while at the same time exploring the reasons (lack of money, resistance) that they may well fail. The optimism that drove Dix, Deutsch, and Maisel is sadly missing from Insane, as are broader policy discussions concerning the current public health crisis around mental-health issues, including gun violence and the opioid epidemic. In the end, though, Roth does point the finger where it belongs. “If, as it is sometimes said, the definition of insanity is doing the same thing over and over again and expecting a different outcome, then there is little doubt that we, who continue to expect the nearly impossible from those least-equipped to handle it, are the crazy ones.”

As we work to end the “era of mass incarceration” that began in earnest in the late twentieth century, we have to reckon with the many ways that jails and prisons currently function, inappropriately and ineffectively, as mental hospitals, and to find just, viable alternatives to replace them. Without fundamental change to both the mental health-care and criminal-justice systems, the seven circles of prison hell will remain open for business for a long time to come.